1386892834 NPI number — ST. JOHN HOSPITAL AND MEDICAL CENTER

Table of content: (NPI 1386892834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386892834 NPI number — ST. JOHN HOSPITAL AND MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. JOHN HOSPITAL AND MEDICAL CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MASONIC URGENT CARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386892834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21099 MASONIC BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLAIR SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48082-1045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-296-6213
Provider Business Mailing Address Fax Number:
586-296-8180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21099 MASONIC BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48082-1045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-296-6213
Provider Business Practice Location Address Fax Number:
586-296-8180
Provider Enumeration Date:
09/08/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
586-228-4560

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 700E034110 . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700E014700 . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700E031610 . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".